United States General Accounting Office GAO Report to Congressional Requesters
September 2001 ATTENTION DISORDER DRUGS Few Incidents of Diversion or Abuse Identified by Schools
GAO-01-1011 Contents
Letter 1 Results in Brief 2 Background 2 Few Incidents of Diversion or Abuse of Attention Disorder Drugs Identified by Schools 6 Most Schools Dispense Attention Disorder Medications and Follow Drug Security Procedures 10 Many States and Local School Districts Have Provisions for School Administration of Medications 15 Conclusions 19 Agency Comments 20
Appendix I Objectives, Scope and Methodology 21
Appendix II Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders 26
Appendix III State Controls on Dispensing of Drugs in Public Schools 33
Appendix IV Anecdotal Accounts of School-Based Diversion or Abuse of Attention Disorder Medications 36
Appendix V Studies Related to Diversion or Abuse of Methylphenidate by School-Aged Children 38
Appendix VI State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students 40
Page i GAO-01-1011 Attention Disorder Drugs Appendix VII GAO Contacts and Staff Acknowledgments 46
Tables Table 1:Rise in Production Quota for Methylphenidate and Amphetamine 5 Table 2:Measures Taken by School Officials as a Consequence of Diversion or Abuse of Attention Disorder Drugs 9 Table 3: School Personnel Dispensing Attention Disorder Medication 13 Table 4: Sample of Schools in Our Study 23
Figures Figure 1: Brand Name Methylphenidate Pills 4 Figure 2: Percent of Middle and High Schools Identifying Diversion or Abuse of Attention Disorder Drugs in the 2000–2001 School Year 7 Figure 3: Diversion or Abuse of Attention Disorder Drugs at Middle and High Schools and by Community Type 8 Figure 4: Percent of Schools Where School Staff Administer Medication by Middle and High Schools and by Community Type 11 Figure 5: Number of Attention Disorder Pills Typically on Hand for Dispensing at School 12 Figure 6: Storage of ADHD and Other Medications 14
Abbreviations
ADHD Attention Deficit Hyperactivity Disorder CCD Common Core of Data DEA Drug Enforcement Administration FDA Food and Drug Administration
Page ii GAO-01-1011 Attention Disorder Drugs United States General Accounting Office Washington, DC 20548
September 14, 2001
The Honorable F. James Sensenbrenner Chairman The Honorable Henry Hyde Committee on the Judiciary House of Representatives
Children diagnosed with attention deficit disorders are commonly treated with stimulant medications, such as Ritalin or Adderall. These drugs are controlled substances under federal law because of their high abuse potential. Many of these stimulant drugs must be taken several times a day to be effective, so that children need medication during the school day. There is some concern that the increase in the use of these medications in a school environment might provide additional opportunities for the diversion or abuse of these drugs. There is no data on the extent to which attention disorder drugs have been diverted or abused at school, or the extent to which state laws or regulations guide local school officials in safely administering these drugs. To clarify these issues, you asked us to provide you with information and analysis on (1) the diversion and abuse of attention deficit disorder drugs in public schools,1 (2) the school environment in which drugs are administered to students, and (3) the state laws or regulations addressing the administration of prescription drugs in schools.
To address the first two objectives, we surveyed principals from a representative national sample of public middle schools and high schools. Elementary schools were not included based on discussion with your staff. For the third objective, we surveyed state Department of Education officials (or their designees) in the 50 states and the District of Columbia. Specific information on our objectives, scope, and methodology is provided in appendix I, and copies of our survey instruments are presented in appendixes II and III.
1 For this report, “diversion or abuse” includes any instances in which the drug was stolen, illegally sold, given away, or traded; possessed or ingested without a prescription; or otherwise involved outside of sanctioned uses.
Page 1 GAO-01-1011 Attention Disorder Drugs Middle and high school principals we surveyed reported little diversion or Results in Brief abuse of attention disorder drugs. For the first 7 to 9 months of school year 2000-2001, approximately 8 percent of principals in public middle and high schools reported knowing of attention disorder drugs being diverted or abused at their school. Most of those principals reported knowing of only one incident. Approximately 89 percent of the principals reported that at their school, the diversion or abuse of attention disorder drugs was less of a problem than other illicit drugs (excluding problems with alcohol and marijuana). We were unable to draw any statistical conclusions about associations between the reporting of incidents and other school characteristics, such as if it was a middle or high school, due to the low number of incidents overall.
Most of the principals reported that school officials administer attention disorder medications, with about 2 percent of the school’s students on average being administered attention disorder drugs on a typical day. Medications are administered by nurses in about 60 percent of the schools, and by non-health professionals, such as secretaries in most of the remaining schools. Medications are kept locked in almost all (96 percent) of the schools according to the principals, and students are observed while taking their medications. We could not draw any statistical conclusions relating incidents to who administers the medications, the number of children on attention disorder medications, variations in storage, or medication transportation due to the low number of incidents overall.
Thirty-seven states and the District of Columbia have either statutes, regulations, and/or mandatory policies addressing the administration of medication to students, based on our survey of state Department of Education officials. State provisions include, for example, that schools obtain written parental authorization to administer medication, ensure that the medication is securely stored, and require prescription medication to be stored in the original pharmacy container. Almost 90 percent of principals reported their school received state and/or local guidance regarding the administration of medications.
Attention deficit disorders are among the most commonly diagnosed Background childhood behavioral disorders. Although there are a number of disorder subtypes, as a group these disorders are referred to as Attention Deficit Hyperactivity Disorder (ADHD). Symptoms include hyperactivity, impulsiveness, and inattention. The American Psychiatric Association’s
Page 2 GAO-01-1011 Attention Disorder Drugs diagnostic manual2 provides criteria for identifying ADHD; however, there is no agreed upon test to confirm an attention disorder. Estimates of the prevalence of the disorder vary widely. A recent international review of 19 epidemiological studies conducted in various countries since 1980 on the prevalence of ADHD in school-age children reported ranges of 2 percent to 18 percent. The review found that the ADHD prevalence rate varies depending on the diagnostic criteria, the children included in the sample, and how the data were collected. Researchers conducting the review concluded with a “best” estimate of between 5 and 10 percent of children and adolescents having some form of this disorder.3
Although controversial, stimulants are the most common treatment for attention disorder symptoms and are the only drugs that are approved by the Food and Drug Administration (FDA) for this purpose. Methylphenidate is the most widely used stimulant, but amphetamines have been increasingly prescribed. Antidepressants, including buproprion and velafaxine, are not approved by the FDA for the treatment of ADHD; however, they are sometimes prescribed by physicians for ADHD if stimulant medications are ineffective or inappropriate for a particular patient.
ADHD drugs come in generic forms, but are often referred to by their brand names. Methylphenidate brand names include Ritalin (see fig. 1), Concerta, Methylin and Metadate. Brand name amphetamines include Adderall, Dexedrine, and Dextrostat. Both types of stimulants are available in quick acting, but short duration (2 to 6 hours) tablets. Recently, sustained or extended release tablets lasting 8 to 12 hours have become available, and a once-a-day skin patch is under development. Longer acting drugs may reduce the need for some children to take their medications at school. Several companies are testing nonstimulant drugs for ADHD treatment that do not have the potential for abuse or physical dependency associated with stimulant drugs.4
2 Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, 4th edition, 2000. Diagnosis consists of a combination of symptoms, such as “often does not seem to listen when spoken to directly,” or “often fidgets with hands or feet or squirms in seat.” 3 Larry Scahill, MSN, PhD and Mary Schwab-Stone, MD, Epidemiology of ADHD in School- Age Children, Child and Adolescent Psychiatric Clinics of North America, Vol. 9(3), (July 2000). 4 Nonstimulant drugs under development and their manufacturers include Atomoxetine (Lilly), GW 320659 (GlaxoSmith Kline), Perceptin (Gilatech).
Page 3 GAO-01-1011 Attention Disorder Drugs Figure 1: Brand Name Methylphenidate Pills
Source: Internet.
Methylphenidate and amphetamines are classified under the federal Controlled Substances Act as Schedule II drugs—those with a high potential for abuse and severe psychological or physical dependence if abused.5 A 1995 Drug Enforcement Administration (DEA) review of methylphenidate concluded that based on studies of laboratory animals and humans, methylphenidate was similar in pharmacological effects to cocaine and amphetamines.6 The DEA establishes annual production quotas for Schedule II drugs by analyzing data on past sales, inventories, market trends, and anticipated need.7
The production quotas for methylphenidate and amphetamines have risen considerably since 1990. (See table 1.) A number of factors have contributed to the increase in the quotas, according to researchers.8 Key
5 See 21 U.S.C. 812(b)(2); 21 C.F.R. 1308.12(d)(1), (4).
6 Drug Enforcement Administration, Drug and Chemical Evaluation Section, Methylphenidate Review Document (Revised October 1995). 7 Controlled Substance Quotas (GAO/GGD-95-52R, Jan. 18, 1995).
8 Daniel J. Safer, Departments of Psychiatry and Pediatrics, John Hopkins University School of Medicine, and Julie Magno Zito, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy. “Pharmacoepidemiology of Methylphenidate and Other Stimulants for the Treatment of Attention Deficit Hyperactivity Disorder” in Ritalin, Theory and Practice, 2nd Edition. M.A. Liebert Publishers, 2000.
Page 4 GAO-01-1011 Attention Disorder Drugs factors include (1) the number of people diagnosed as having ADHD has grown with an expansion in the criteria used to diagnose ADHD; (2) longer periods of treatment for the disorder; (3) more girls are receiving medication than in prior years; and (4) a greater public acceptance of psychopharmacologic treatment of youth. According to data obtained by DEA, about 80 percent of the prescriptions for amphetamines and methylphenidate were to treat children with ADHD.
Table 1:Rise in Production Quota for Methylphenidate and Amphetamine
1990 DEA production 2000 DEA production quota in kilograms quota in kilograms Methylphenidate (percent 1,768 14,957 increase) (746) Amphetamine (percent 417 9,007 increase) (2060) Source: DEA.
Along with the increase in the use of stimulant medications have come concerns that these drugs may be being diverted from their prescribed use, or otherwise abused. School settings are perceived as particularly vulnerable for abuse because schools store attention disorder drugs for students needing medication while at school. DEA interviews in 1997 with schools officials in three states indicated that schools might leave medications in unsecured locations, such as teachers’ desks, making theft possible. A number of anecdotal news accounts of students abusing these drugs at school have heightened concerns. (See app. IV.) However, no studies are available to document the degree to which these medications are diverted at school. There is some evidence from a small number of studies and national data that abuse of these drugs does occur. (See app. V.) For example, the University of Michigan has surveyed a national sample of public and private 8th, 10th, and 12th grade students since 1991. Of 12th graders surveyed in 2000, 2 percent reported using Ritalin without a prescription in the past year. The University of Michigan survey does not specify where drug use occurred.
Page 5 GAO-01-1011 Attention Disorder Drugs Few Incidents of Based on our survey, an estimated 8 percent9 of principals in public middle schools and high schools in the United States reported at least one Diversion or Abuse incident of diversion or abuse of attention disorder drugs during the current 2000-2001 school year. (See fig. 2.) Most of those principals of Attention Disorder reported knowing of only one incident at their school.10 An additional 3 Drugs Identified percent of school principals reported at least one possible incident, but by Schools were uncertain of the drugs involved.
9 The results presented here are estimates based on a random sample of middle and high school principals. This sample is only one of a large number of possible samples that could have been drawn. Since each sample could have produced different estimates, we present the estimate with a confidence interval (an upper and lower bound). Unless noted, the 95- percent confidence interval for survey estimates is within +/-10 percent. This means that for the principal survey percentages presented in this report, we are 95-percent confident that the results we would have obtained if we had contacted all middle and high school principals (rather than a sample) are within +/- 10 or fewer percentage points of our results. 10 The 95-percent confidence interval for incidents per school is within +/-16 percent.
Page 6 GAO-01-1011 Attention Disorder Drugs Figure 2: Percent of Middle and High Schools Identifying Diversion or Abuse of Attention Disorder Drugs in the 2000–2001 School Year
Percent of all Incidents Middle and per school High Schools
89% 8% 1 5% 2 1% 3% 3 to 5 1% 6 or more 0.3%
No incident
Possible incident
Incident
Source: GAO survey.
Of the 8 percent reporting an incident of diversion or abuse in the current school year, only methylphenidate was involved at 73 percent of the schools, and only amphetamines were involved at 20 percent of the schools.11 In the remaining cases, the specific drug could not be determined or both drugs were involved. Using the U.S. Department of Education designations for community, we classified schools as being located in central cities, urban communities, or small towns.12 We compared incident rates by school and community type. (See fig. 3.) Due to the low number of incidents overall, we were unable to draw any
11 The 95-percent confidence interval for the type of drug involved in the incident is within +/- 16 percent. 12 Central city communities include central cities of Metropolitan Statistical Areas or central cities in Consolidated Metropolitan Statistical Areas; urban communities include those located on the urban fringe of large- or mid-sized cities or large towns; small towns include small towns and rural areas. (See Scope and Methodology in app. I.)
Page 7 GAO-01-1011 Attention Disorder Drugs statistical conclusions about possible association between these factors and the incidence rate.
Figure 3: Diversion or Abuse of Attention Disorder Drugs at Middle and High Schools and by Community Type
100%
15 15 15% 14% 13 13% 12% 11 11 11 11% 10% 9% 8% 7% 6 6 6 6% 5 5 5% 4 4% 3% 2% 1% 0% All Schools Middle High Central City Urban Small Town Schools Schools Schools Schools Schools
Confidence interval: displays the upper and lower bounds of the 95% confidence interval for each estimate. Source: GAO survey.
Principals reporting any incident at their school were asked to briefly describe the incident for which they had the most information. A content analysis of the 51 incidents described by our sample respondents showed that in 38 cases the student gave or sold pills to other students. For example, “Student brought Adderall to school and attempted to sell it to other students.” A second type of incident (4 cases) involved pills being stolen from other students or the school. The remaining incident descriptions were varied, such as “In all (6) cases, a pill was found outside the entrance to the main building. We aren’t sure if it is a student taking the medication at school or bringing it from home and dropping it outside.”
The students involved in the estimated 8 percent of schools with reported diversion or abuse incidents were most often expelled or suspended from school as a consequence of the incident, according to principals. Other measures taken by schools in response to the incident are shown in table 2. An estimated 42 percent of the principals that were aware of an incident did not call police regarding the drug diversion or abuse incident.
Page 8 GAO-01-1011 Attention Disorder Drugs Consequently, measures of attention disorder diversion or abuse based on official police records may underreport actual occurrences.
Table 2:Measures Taken by School Officials as a Consequence of Diversion or Abuse of Attention Disorder Drugs
Measure taken Percent of schoolsa Student was expelled or suspended 78 Police were called 58 Student was counseled 54 Other measures were takenb 41 School policies or procedures were changed 0 No measures were taken 0 aThe 95-percent confidence interval for percent of schools taking specific measures is within +/-16 percent. bOther measures included discussions with parents, transfer to an alternative school, or involving youth services. Source: GAO survey.
Most principals did not perceive the diversion or abuse of prescribed attention disorder drugs to be a major problem at their school. An estimated 89 percent reported that it was less of a problem than other illicit drug use, excluding alcohol and marijuana. In general, illicit drug use (excluding alcohol and marijuana) was reported to be not a problem at all or a minor problem by approximately 78 percent of the principals. In addition, the most frequent comments voluntarily written by principals were comments regarding the lack of an ADHD medication abuse problem at their school. For example, one principal stated that “I feel comfortable in stating that there is ‘NO DIVERSION’ of medication that is administered through the office/clinic.” We compared incident rates by the principal’s assessment of the problem, but were unable to draw any statistical conclusions about a possible association due to the low number of incidents overall.
Page 9 GAO-01-1011 Attention Disorder Drugs Most school officials reported that attention disorder medications are Most Schools administered to students during the school day, most often by a nurse. Dispense Attention However, only a small fraction (less than 2 percent13) of a school’s students were reported to receive these drugs. Most schools reported that Disorder Medications drugs were stored in locked cabinets or rooms, and that students are and Follow Drug observed when they take their medications. Security Procedures
Medication Administration Nationally, an estimated 90 percent of schools have school staff administering attention disorder medication to some students on a typical day, according to principals we surveyed. Schools that do not typically administer these drugs may have policies that prohibit dispensing medication, or do not have students currently requiring attention disorder medication during school hours. As shown in figure 4 estimates, statistically more middle school officials (96 percent) administered ADHD medications than did high school officials (83 percent). However, incident estimates by community type were not statistically different.
13 The estimated fraction of students that receive these drugs is 1.7 percent and is surrounded by a 95-percent confidence interval extending from 1.5 percent to 1.9 percent.
Page 10 GAO-01-1011 Attention Disorder Drugs Figure 4: Percent of Schools Where School Staff Administer Medication by Middle and High Schools and by Community Type
100% 98 92 93 94 94 90% 93 87 87 86 80% 84 84 77 70%
60%
50%
40%
30%
20%
10%
0% All Schools Middle High Central City Urban Small Town Schools Schools Schools Schools Schools
Confidence interval: displays the upper and lower bounds of the 95% confidence interval for each estimate. Source: GAO survey.
While 90 percent of principals in our study population reported that their schools administer attention disorder medications, a relatively small fraction of students attending these schools were administered attention disorder medications while at school. An estimated 1.1 percent14 of students (in schools where drugs are administered) were dispensed methylphenidate and an estimated 0.5 percent15 of students were administered amphetamines, for an overall rate of almost 2 percent.
A DEA drug diversion official expressed concern during recent congressional testimony16 with the volume of methylphenidate on hand at school for student daytime dosing. Our survey found that 6 percent of schools stored 600 pills or more, while over half of the schools stored 100 pills or less. (See fig. 5.)
14 The 95-percent confidence interval for this estimate extends from 1.0 to 1.3 percent.
15 The 95-percent confidence interval for this estimate extends from 0.47 to 0.59 percent.
16 Terrance Woodworth, Deputy Director, Office of Diversion Control, DEA, before the House Committee on Education and the Workforce, Subcommittee on Early Childhood, Youth and Families (May 15, 2000).
Page 11 GAO-01-1011 Attention Disorder Drugs Figure 5: Number of Attention Disorder Pills Typically on Hand for Dispensing at School
100 to 199 50 to 99
17% 15%
15% 200 to 399
36% 6% 400 to 599 6% Less than 50 5% 600 or more
Unknown Source: GAO survey.
At schools that dispense attention disorder medications, the personnel approved to administer medications varied among schools. Nurses were reported to most often carry out that task, and second to nurses, nonhealthcare professionals, such as secretaries, most often dispense medications. (See table 3.) Lack of a nurse or other trained healthcare professional was noted as a concern by several principals. Of the 107 optional comments written by principals in our survey, 13 comments were about the need for nurses to administer medication to students. For example, one wrote, “School districts should be forced to provide full- time nursing services so that only medically-trained personnel can distribute medication.”
Page 12 GAO-01-1011 Attention Disorder Drugs Table 3: School Personnel Dispensing Attention Disorder Medication
Percent approved to Percent most often administer attention administering attention Personnel disorder medicationa disorder medicationsb Nurse 75 59 Other healthcare professional 13 7 Principal 32 2 Teacher 12 2 Other nonhealthcare professional 51 28 Students self-administer 61 aThe column total does not equal 100 percent because more than one person can be approved to dispense medication. bThe column total does not equal 100 percent because of rounding.
For nonhealthcare professionals administering attention disorder medications, all but 5 percent of school officials reported some kind of training was provided to prepare staff for their duties. Principals reported multiple forms of training for staff. Training was provided by written instruction at 41 percent of schools, by healthcare professionals in about 49 percent of the schools, by oral instruction at 49 percent of schools, and 9 percent were provided video instruction.
Medication Security Most school principals reported that ADHD medications are kept in locked spaces. Approximately 72 percent of the schools that dispense attention disorder medications store the drugs in a locked cabinet and a locked office or room. Examples of this type of storage are shown for schools “A” and “B” in figure 6. An additional 24 percent of schools kept medications in either a locked cabinet or a locked office or room. Some school principals noted that during nonschool hours medication security was tighter, such as locking the room in which medication was stored in addition to a locked cabinet, or using a vault. Of those reporting that medications were kept locked, the average number of people with access was three people, and at most schools (93 percent) fewer than six persons have access to the medications. Because most schools secure attention disorder medications in locked storage, and the low overall rate of diversion or abuse, we were unable to draw statistical conclusions about any possible association between number of incidents, medication security, or security and school type.
Page 13 GAO-01-1011 Attention Disorder Drugs Figure 6: Storage of ADHD and Other Medications
Medication in cabinet at school A Cabinet and door locks at school A
Medication in cabinet at Cabinet and door locks school B school B
Source: GAO.
Page 14 GAO-01-1011 Attention Disorder Drugs Almost all (96 percent) of the school principals in schools that administer medications reported that students are observed when they are administered medication to assure that it is taken.
Of the 90 percent of schools that administer attention disorder medications, about 48 percent have parents only transporting student medications from home to school. Another 34 percent of schools allow either parents or students to transport medications and 12 percent had students transporting their own medications. Among those schools that have students transporting their own medications, several principals commented that controls were in place to assure that none of the medication was diverted from home to school. For example, one principal reported that the medication bottle must be taped closed with the number of pills inside indicated on the bottle and accompanied by a note signed by the parent. We compared incident rates by how the medications were transported to school, but were unable to draw any statistical conclusions due to the low number of incidents overall and the distribution of responses.
Many states in the United States have statutes, regulations, and/or Many States and Local mandatory policies regarding the administration of medication at schools. School Districts Have At the local level, most of the principals in our survey of middle and high schools reported having school district provisions regarding the Provisions for School administration of medication. Administration of Medications
Many States Have From our survey of state education officials (see app. III), we determined Established Requirements that 37 states and the District of Columbia have statutes, regulations, for the Administration of and/or mandatory policies addressing medication administration at schools, as shown in appendix VI.17 The remaining 13 states do not, as Medication discussed in the following sections.
Of the 37 states with applicable provisions, 29 require or authorize schools to adopt medication administration policies; in most of these states, schools issuing policies for the administration of medication must incorporate minimum statewide requirements. The other eight states and
17 Two states, Oregon and Ohio, did not respond to the survey, and we researched these states’ statutes and regulations as reported in the Lexis and Westlaw databases.
Page 15 GAO-01-1011 Attention Disorder Drugs the District of Columbia do not expressly delegate authority to local schools, but provide for the regulation of medication administration in schools based on statewide or districtwide requirements.
We analyzed provisions in the 37 states and the District of Columbia based on five common statewide requirements for administering medication at schools: (1) whether schools must obtain authorization from the student’s parent or guardian to administer medication, (2) whether schools must obtain written orders or instructions from the student’s physician or other licensed medication prescriber to administer medication, (3) whether schools must receive and store prescription medication in an original container with proper pharmaceutical labeling, (4) whether schools must provide storage for medication that is secure and inaccessible except to authorized school personnel, and (5) whether schools must document the administration of medication to the student in a medication log.
Although these five categories represent the more common statewide requirements, they do not represent the full array of state requirements that regulate the administration of medication in schools. For example, Maine and New Jersey have minimum state requirements for school medication administration policies, but not in one of the five categories reflected in appendix VI. Maine requires that all unlicensed personnel receive training before administering medication, while New Jersey prohibits anyone other than a doctor, nurse, or parent from administering medication in a non-emergency situation.18 Other states limit the amount of medication that schools may store; require parents or guardians to deliver medications to schools; establish procedures for returning and/or destroying any unused medications; and establish safeguards specific to self-administration of medications by students.
From our review, we found that 28 states and the District of Columbia require that schools obtain authorization from the student’s parent or guardian before administering medication. Virtually all of these jurisdictions specifically require written authorization. In addition, 19 states and the District of Columbia require that schools obtain orders or instructions from the student’s physician or other licensed medication prescriber before administering medication. In most of these jurisdictions, the requirement for a medication order is met if the prescriber provides specific instructions for administration (e.g., the name, route, and dosage of the medication and the frequency and time of the administration).
18 See 20-A Me. Rev. Stat. Ann., sec. 254, subsec. 5; N.J. Admin. Code 6A:16-2.3(b)(1).
Page 16 GAO-01-1011 Attention Disorder Drugs However, in two states, Utah and Washington, schools must also obtain a written statement from the prescriber that administering medication at school is medically necessary or advisable.19 Finally, 22 states and the District of Columbia require schools to obtain prescription medication in an original container with proper pharmaceutical labeling.20
Eighteen states specify the manner in which schools must store medication to ensure its security.21 These states vary in terms of the level of security required. States such as Indiana, Iowa, and Oklahoma simply require a secure or inaccessible location to store medication.22 However, most states specify locked storage for medication and a few impose more stringent security measures. For example, Massachusetts requires schools to store prescription medications in a securely locked cabinet, which is substantially constructed and anchored to a solid surface, with access to keys restricted.23
Sixteen states require schools to document the administration of medication to the student in a medication log or other like-named record.24 Documentation requirements vary between these states. Although some of the states do not specify the content or format of the medication log, many
19 See Utah Code Ann. 53A-11-601(1)(b)(ii); Rev. Code. Wash. 28A.210.260.
20 In appendix VI, we express the requirement in these 22 states and the District of Columbia as a requirement for a “pharmacy container.” However, not all states, nor the District, use this terminology. Some require schools to obtain medication that is properly labeled and/or in its original container. In the case of prescription medications, we interpreted such laws as essentially requiring a pharmacy container. 21 Some states (e.g., Oregon, Utah, Wisconsin, and Wyoming) require schools adopting medication administration policies to address the safe storage of medication, but do not specify any minimum requirements that the schools’ policies must incorporate. See Or. Admin. Rules, 581-021-0037(4)(a); Utah Code Ann. 53A-11-601(1)(a)(ii); Rev. Code. Wash. 28A.210.260(1); Wyo. Admin. Code, Educ., ch. 6, sec. 17(a)(i)(F). We did not regard these states as imposing secured storage requirements, in contrast with the 18 states that do specify minimum requirements that schools must observe in storing medication. 22 See 511 Ind. Admin. Code 7-21-8(a)(4); 281 Iowa Admin. Code 41.12(11)(h); 70 Okla. Stat. Ann. 1-116.2(D). 23 See 105 Code of Mass. Reg. 210.008(C), (D).
24 Colorado, the District of Columbia, New Mexico, and Wisconsin require “record keeping” or “documentation,” but do not specifically state that schools must maintain records of administering medication to students. See Colo. Dept. of Reg. Agencies, ch. XIII, sec. 7.5; D.C. Code 31-2434(a)(4); 6 N.M. Admin. Code 4.2.3.1.11.3.2 (e); Wis. Stat. 118.29(4). Absent such specificity, we did not treat these jurisdictions as requiring medication logs, in contrast with the 16 states discussed above.
Page 17 GAO-01-1011 Attention Disorder Drugs require, at a minimum, that the log reflect the date, time, and dosage of the medication given to the student, and the name or signature of the person administering the medication. A few states impose additional documentation requirements. For example, along with other states, Connecticut requires schools to document any skipped dose and the reason for it; Maryland requires scheduled pill counts for controlled substances and reconciliation against the medication log; and Massachusetts requires schools to document the return of any unused medication to the student’s parents.25
From our survey responses, we found that 13 states do not have applicable statutes, regulations, or mandatory policies addressing the administration of medication in schools, as reflected in appendix VI. Although 5 of the 13 states (Idaho, Kansas, Missouri, Montana, and New York) identified provisions in their survey responses, the cited provisions cover areas that are not directly within the scope of our inquiry and are not included in appendix VI. For example, Missouri and New York have statutes addressing when a student with asthmatic conditions may carry and use a prescribed inhaler at school.26 Thus, appendix VI does not include every provision cited by a survey respondent, only those provisions relevant to our work.
Finally, during our survey, 22 states and the District of Columbia reported that they have policy guidelines addressing the administration of medication in schools.27 The policies in these jurisdictions are discretionary and do not create legal requirements for administering medication in schools, as do the statutes, regulations, and mandatory policies reflected in appendix VI. Nevertheless, the discretionary policies often contain detailed recommendations to assist schools adopting medication administration policies. The discretionary policies cover the same broad range of medication administration procedures reflected in the various state statutes, regulations, and mandatory policies. Only seven
25 See Regs., Conn. State Agencies 10-212a-6(a)(1)(K); 105 Code of Mass. Reg. 210.008(G). Maryland’s requirements appear in a mandatory policy jointly issued by state administrative agencies. 26 See Mo. Rev. Stat. 167.627; N.Y. Cons. Law Serv., Educ., sec. 916. 27 The states are Alabama, Arkansas, California, Delaware, Florida, Illinois, Iowa, Kentucky, Louisiana, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, South Dakota, Vermont, Virginia, Washington, and Wisconsin.
Page 18 GAO-01-1011 Attention Disorder Drugs states have no applicable statutes, regulations, or policies (discretionary or mandatory) addressing the administration of medication in schools.28
Many School Districts Lack of a state policy on the administration of medication does not Have Established Local prevent schools in a state from developing their own provisions, and most Procedures have. According to responses in our survey of school principals, 90 percent of schools have received district regulations or policies regarding the administration of prescription medications. For example, South Carolina officials reported that the state has no statutes, regulations, or policies in this area; however, the Charleston County School District medication administration policy mirrors many of the policies developed by other states. For example, the Charleston district requires that written medication requests be completed by the prescribing physician and parent, that medication be delivered by the parent in its original container, that medication be kept locked at the school, and be administered by a nurse or designated staff.
An estimated 17 percent of school principals reported that their school policy had recently changed regarding the administration of prescription drugs to students. Of the 17 percent reporting a policy change in the last 2 years, 29 percent29 reported that the change was due to problems with the handling of medications at the principal’s school or at a neighboring school.
We do not believe that the diversion or abuse of attention disorder Conclusions medications is a major problem at middle or high schools. Based on our findings, few middle or high school principals are aware of ADHD medication diversion or abuse, and most do not believe this is a major problem. Furthermore, states and localities appear to be cognizant of the potential for problems and many have established policies and procedures to minimize risks. Finally, the development of nonstimulants for attention disorders and increasing use of once-a-day stimulant medications may reduce the potential for diversion or abuse at school by reducing the need for the medications to be administered during school hours.
28 The states are Alaska, Georgia, Idaho, Kansas, Mississippi, Montana, and South Carolina.
29 The 95-percent confidence interval for this estimate extends from 19 to 41percent.
Page 19 GAO-01-1011 Attention Disorder Drugs Agency comments were not requested for this report because no federal Agency Comments agency or federal policies were reviewed. We did discuss our findings with the Drug Enforcement Administration’s Office of Diversion Control prior to the completion of our report and have incorporated changes where necessary.
We will send copies of this report to the Ranking Member, House Committee on the Judiciary; the Chairman, Senate Committee on the Judiciary; the Ranking Member, Senate Committee on the Judiciary; the Administrator, Drug Enforcement Administration; and other interested parties. Copies of this report will be available on GAO’s homepage at http://gao.gov.
The major contributors to this report are acknowledged in appendix VII. If you or your staffs have any questions about this report, please contact me at (202) 512-8777 or Darryl W. Dutton at (213) 830-1000.
Paul L. Jones Director, Justice Issues
Page 20 GAO-01-1011 Attention Disorder Drugs Appendix I: Objectives, Scope and Appendix I: Objectives,Methodology Scope and Methodology
Our objectives in this review were to (1) determine the prevalence of Objectives diversion and abuse of attention disorder drugs in public schools, 2) describe the school environment in which drugs are administered to students, and (3) obtain information on state laws and regulations regarding the administration of prescription drugs in schools.
We conducted our review between February and June 2001 in accordance with generally accepted government auditing standards.
To attain our objectives, we surveyed a statistically representative random Survey Scope and sample of public school principals. We focused our attention on middle Methodology schools and high schools, which we defined as schools containing grades 6 or higher. Specifically, we asked these principals a series of questions about any incidents of diversion and abuse of attention disorder drugs at their school since the beginning of the 2000-2001 school year. We also asked a number of questions covering school policies and practices on the administration and storage of these types of attention disorder drugs.
The study population for the survey of public school principals consisted Study Population of all public schools in the 2000-2001 school year that have at least one grade between 6th and 12th (inclusive), more than 1 teacher, and a total of at least 10 students.1 The sample was drawn from a list of all public schools in the United States compiled by The Common Core of Data (CCD) for the 1998-99 school year. The CCD is the U.S. Department of Education’s primary database on public elementary and secondary education in the United States. We used the 1998-99 CCD file to produce a list of schools representing our study population. From this list of 35,522 schools, we drew a random sample of 1,033 schools to represent the study population in the 50 states and the District of Columbia.
Of the 1,033 surveys we mailed out, 735 completed surveys were returned, a response rate of 71 percent. See appendix II for a copy of our survey instrument.
1 Schools with a high grade of 6th and a low grade of 3rd or less are excluded from our study population. We did not include elementary schools based on discussion with our requestor.
Page 21 GAO-01-1011 Attention Disorder Drugs Appendix I: Objectives, Scope and Methodology
The sample design for this study is a single-stage stratified sample of Sample Design schools in the study population. The strata were defined in terms of type of school (middle school, high school, etc.) and community type2 (city, urban, or small community). Since type of school was not available on the sample frame, we developed criteria based on the highest and lowest grade level reported for the school. The first six strata consist of schools for which an unambiguous assignment to middle school or high school can be made. An additional three strata consist of upper grade schools that have grade levels that overlap between the middle school and high school definitions. The following rules are used to assign middle, high, or high/middle school type:
High school – Schools on the CCD having their high grade and their low grade between 9th and 12th grade, inclusive.
Middle school – Schools on the CCD having their high grade between 6th and 9th, inclusive. In addition the low grade for the school must be 8th or below (but not less than 4th grade).
High/middle – Schools with at least one grade that is greater than or equal to 6th grade, no grades less than 4th grade, and not meeting the above definitions for high school or middle school.
Finally, we sampled another six residual strata that are composed of schools that would meet either the “middle school” or the “high/middle school” definition, except for the presence of some grades less than the 4th grade.
The strata definitions, population sizes, and sample sizes are summarized below.
2 “City” is defined as a central city of Consolidated Metropolitan Statistical Area (CMSA) or as a central city of a Metropolitan Statistical Area (MSA). “Urban” refers to Urban Fringe (an incorporated place, Census Designated Place, or nonplace territory within a CMSA or MSA of a city and defined as urban by the Census Bureau) or to a large town (an incorporated place or Census Designated Place with a population greater than or equal to 25,000 and located outside a CMSA or MSA). A “small community” is an incorporated place or Census Designated Place with a population less than 25,000 and greater than 2,500 located outside a CMSA or MSA, or any incorporated place, Census Designated Place, or nonplace territory designated as rural by the Census Bureau.
Page 22 GAO-01-1011 Attention Disorder Drugs Appendix I: Objectives, Scope and Methodology
Table 4: Sample of Schools in Our Study
Stratum Definition Population Sample Respondents 1 Middle school, city community 3,220 148 100 2 Middle school, urban community 5,953 148 111 3 Middle school, small community 5,553 148 117 4 High school, city community 2,118 148 108 5 High school, urban community 4,236 148 109 6 High school, small community 5,251 148 101 7 High/middle school, city community 238 8 4 8 High/middle school, urban community 729 12 9 9 High/middle school, small community 2,517 33 25 10 Middle school with <=3rd grade, city community 1,042 24 10 11 Middle school with <=3rd grade, urban 1,009 13 6 community 12 Middle school with <=3rd grade, small 2,582 34 23 community 13 High/middle school with <=3rd grade, city 98 5 4 community 14 High/middle school with <=3rd grade, urban 155 5 2 community 15 High/middle school with <=3rd grade, small 821 11 6 community Total 35,522 1,033 735
Estimates produced in this report are for schools in our study population Estimates that could be classified as either a middle school or a high school for the 2000-2001 school year. Although the sample was stratified according to 1998-99 grade levels at the school, estimates are produced for type of school (middle and high school) as determined from the responding school’s grade composition for the 2000-2001 school year. The survey responses provide each school’s lowest and highest grade for the 2000- 2001 school year, and these data were used to classify the responding schools as a middle school or as a high school according to the definition shown below. Of the 735 surveys returned, 596 could be classified as either a middle school or as a high school. Data from schools that could not unambiguously be classified as middle or as a high school are not included in our estimates of middle or high school characteristics.
High school – Responding schools having their high grade and their low grade between 9th and 12th grade, inclusive, for the 2000-2001 school year.
Middle school – Responding schools having their high grade between 6th and 9th, inclusive, for the 2000-2001 school year. In addition, the low grade for the school must be 8th or below (but not less than 4th grade).
Page 23 GAO-01-1011 Attention Disorder Drugs Appendix I: Objectives, Scope and Methodology
These definitions are consistent with those used in the definition of the survey’s sampling strata, except that the low and high grade is based on 2000-2001 school year data instead of on the 1998-99 CCD data.
Because we surveyed a sample of public school principals, our results are Sampling Error estimates of all participants’ characteristics and thus are subject to sampling errors that are associated with samples of this size and type. Our confidence in the precision of the results from this sample is expressed in 95-percent confidence intervals. The 95-percent confidence intervals are expected to include the actual results for 95 percent of the samples of this type. We calculated confidence intervals for our study results using methods that are appropriate for a stratified, probability sample. For the percentages presented in this report, we are 95-percent confident that the results we would have obtained if we had studied the entire study population are within +/- 10 or fewer percentage points of our results, unless otherwise noted. For example, a nurse administers medications at an estimated 59 percent of the middle and high schools. The 95-percent confidence interval for this estimate would be no wider than +/- 10 percent, or from 49 percent to 69 percent. For estimates other than percentages (including estimates of ratios), 95-percent confidence intervals are +/- 10 percent or less of the value of the estimate, unless otherwise noted.
In addition to these sampling errors, the practical difficulties in conducting Nonsampling Error surveys of this type may introduce other types of errors, commonly referred to as nonsampling errors. For example, questions may be misinterpreted or the respondents’ answers may differ from those of people who did not respond. We took several steps in an attempt to reduce such errors. For example, we developed our survey questions with the aid of a survey specialist. We discussed the questionnaire with officials at the American Association of School Administrators and the National Association of Secondary School Principals. We held discussions or pretested the questionnaire with 10 public school principals. All initial sample nonrespondents were sent at least one follow-up questionnaire mailing. All data were double keyed during data entry, and GAO staff verified a sample of the resulting data. Computer analyses were performed to identify inconsistencies and other indications of errors, and a second independent analyst reviewed all computer programs.
To obtain information on state laws and regulations regarding the Other Data Scope and administration of prescription drugs in schools, we conducted a brief Methodology survey of state department of education officials (or persons designated by
Page 24 GAO-01-1011 Attention Disorder Drugs Appendix I: Objectives, Scope and Methodology
officials) in the 50 states and the District of Columbia. The survey requested information on all state statutes, regulations, or other written policies regarding the administration of prescription drugs to students in public schools. As was the case with the survey of public school principals, the questionnaire sent to the state education officials was developed with the aid of a survey specialist, was reviewed by an attorney, and was pretested. See appendix III for a copy of this survey instrument. We received survey responses from 48 states and the District of Columbia, and we verified the accuracy of the survey information by researching the states’ statutes and regulations. Likewise, we researched the statutes and regulations of the two states that did not respond (Ohio and Oregon). We focused on five types of medication administration requirements that appeared in many states as the basis for analyzing the various state laws.
As background, we searched Lexis-Nexis and Proquest databases for anecdotal evidence of diversion and abuse of attention disorder medications in schools. Using only the information provided in the resulting pool of articles, specific incidents described in each article were identified, matched for duplication where evidence allowed, and summarized. We did not verify the reliability or validity of the reports.
Page 25 GAO-01-1011 Attention Disorder Drugs Appendix II: Survey of Public School Principals – Appendix II:Diversion/Abuse Survey of Medication of for Attention Public Disorders School Principals – Diversion/Abuse of Medication for Attention Disorders
Page 26 GAO-01-1011 Attention Disorder Drugs Appendix II: Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders
Page 27 GAO-01-1011 Attention Disorder Drugs Appendix II: Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders
Page 28 GAO-01-1011 Attention Disorder Drugs Appendix II: Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders
Page 29 GAO-01-1011 Attention Disorder Drugs Appendix II: Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders
Page 30 GAO-01-1011 Attention Disorder Drugs Appendix II: Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders
Page 31 GAO-01-1011 Attention Disorder Drugs Appendix II: Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders
Page 32 GAO-01-1011 Attention Disorder Drugs Appendix III: State Controls on Dispensing of Drugs in Appendix III:Public Schools State Controls on Dispensing of Drugs in Public Schools
Page 33 GAO-01-1011 Attention Disorder Drugs Appendix III: State Controls on Dispensing of Drugs in Public Schools
Page 34 GAO-01-1011 Attention Disorder Drugs Appendix III: State Controls on Dispensing of Drugs in Public Schools
Page 35 GAO-01-1011 Attention Disorder Drugs Appendix IV: Anecdotal Accounts of School-Based Appendix IV: AnecdotalDiversion or AbuseAccounts of Attention of School- Based Diversion or AbuseDisorder Medications of Attention Disorder Medications
We reviewed the anecdotal1 accounts of school-based diversion or abuse of attention disorder medications to provide an indication of the public perception of diversion and abuse of attention disorder medications at schools. We searched two major on-line databases for the period January 1996 to February 2001 for anecdotal accounts. The databases include articles from over 30,000 sources, including every major U.S. newspaper, magazines, and other published sources. Because of the nature of news coverage, no conclusions can be drawn from these accounts. We did not verify the reliability or validity of the identified incidences.
While school-based attention disorder medication diversion or abuse was identified, the extent of problems was somewhat overstated by repeated descriptions of incidents. Most of the articles identified in our review of 5 years of news accounts focused on concerns about the over-prescription of Ritalin. Excluding these articles, about 250 articles mentioned one or more incidences of school-based abuse of attention disorder medications. Closer examination of these accounts indicated that many of the same incidents were repeated in different articles. Using only information about the incidents provided in the news accounts, about 130 of the incidents within the 5-year period appeared to be unique incidents. For example, an abuse incident at an Illinois middle school was mentioned in over 10 different articles. A sample of the accounts:
“Administrators at xx Middle School had heard about Ritalin Abuse for almost three years, Principal X said. But they did not know of abuse within the school until a teacher spotted two students passing something in a restroom last month. Since then, 15 students have been suspended.” Cincinnati Post (Cincinnati, OH) May 8, 2000.
“Fifteen students at xx Middle School are suspected of abusing the prescription drug Ritalin. According to details of the investigation of this incident, students gave away the tablets or sold them for 50 cents to $1.” Daily Herald (IL) May 8, 2000.
“Now comes word that the drug used to control the disorder – Ritalin – is being used recreationally by people who certainly don’t need it…. At xx Middle School, 15 students were suspended recently for this.” The Deseret News (Salt Lake City, UT) May 6, 2000.
While most of the incidents identified involved students caught selling or stealing the medications at school, about 20 anecdotal incidents involved
1 We define news accounts as “ancecdotal” because such accounts are not presented along with evidence that allows the accuracy of the reports to be verified, nor is there any pretext that news accounts coverage is comprehensive or otherwise systematically presented.
Page 36 GAO-01-1011 Attention Disorder Drugs Appendix IV: Anecdotal Accounts of School-Based Diversion or Abuse of Attention Disorder Medications
theft or abuse by a teacher, principal, nurse, or other school personnel. For example, in one anecdotal incident, a principal was arrested on charges that he stole Ritalin pills from the school medicine cabinet. Anecdotal incidents were reported in 37 out of 50 states.
Page 37 GAO-01-1011 Attention Disorder Drugs Appendix V: Studies Related to Diversion or Abuse of Methylphenidate by School-Aged Appendix V: StudiesChildren Related to Diversion or Abuse of Methylphenidate by School-Aged Children
Study Findings Measure of abuse Study population Monitoring the Future Ritalin Abuse 12th Grade Students are asked if they have used any Since 1991, a representative National Institute on 2000 of a wide range of drugs, including alcohol national sample of public Drug Abuse and tobacco. Only students who answered and private school 8th, 10th, University of Annual Use 2.2% “yes” to the use of amphetamines are then and 12th graders have been Michigan asked to specify the type of amphetamine surveyed annually, a sample used, with Dexedrine and Ritalin as two of of about 50,000 students the amphetamine type choices.a overall in 420 public and private schools. Indiana Prevention Ritalin Abuse 12th Grade Students are asked about their lifetime, Since 1991, 6th through 12th Resource Center 1999 2000 annual, monthly, and daily use of specific graders in Indiana have drugs, including their nonprescribed use of been surveyed on their use Lifetime Use 7.4% 7.4% Ritalin and of amphetamines, which are of amphetamines, and since Annual Use 4.3% 4.8% described in the survey as “uppers.” 1998 on their nonprescribed use of Ritalin. Monthly Use 1.5% 1.9% Massachusetts Ritalin Abuse Students are asked about use of Ritalin Every 3 years since 1984, Department of Public 7th–12th Grade without a prescription in their lifetime and the state has surveyed 6th Health 1999 within the last 30 days. through 12th graders. The 1999-2000 survey of Lifetime Use 9.7% approximately 7,000 students was the first to Monthly Use 3.3% include questions specifically about Ritalin. National Household Nonmedical Use Of Any Interviewees are asked about their use Since 1971, random Survey on Drug Psychotherapeutic and frequency of use of various licit and samples of households Abuse 12 to 17 Years Old illicit drugs. Nonmedical use of any throughout the United States 1999 psychotherapeutic includes any have been interviewed at prescription-type pain reliever, tranquilizer, their place of residence. In Lifetime Use 10.9 % stimulant, or sedative. 1999, 66,706 persons including 12 to 17 year olds Monthly Use 2.9 % were interviewed. Drug Abuse Warning Drug Treatment Episodes Within each facility participating in DAWN, Since 1988, data on Network (DAWN) Methylphenidate (Ritalin) a designated reporter, usually a member emergency department drug Substance Abuse 1999 of the emergency department or medical related visits has been and Mental Health records staff, is responsible for identifying collected from a Services 0.27%b drug-related episodes and recording and representative sample of Administration submitting data on each case. U.S. acute care hospitals, including 21 oversampled metropolitan areas. The 1999 sample consisted of 592 hospitals. Arrestee Drug Abuse Juvenile Amphetamine Use Arrestees are asked about taking specific More than 2,500 juvenile Monitoring % Tested Positive drugs, including amphetamines “like male detainees in 9 sites National Institute of (Range at different cities) Ritalin,” on a lifetime, annual, monthly, and and more than 400 juvenile Justice 1999 48-hour basis. A general question is asked female detainees in 6 sites to include other drugs not specifically are administered urine tests mentioned. and interviewed in detail Male 0 to 16% about their drug taking, Female 0 to 18% purchases and other drug- related questions. Note: Some of these surveys also ask about amphetamines; however, those results are not reported here because they do not distinguish between amphetamines acquired through diversion from ADHD prescriptions and those illegally manufactured.
Page 38 GAO-01-1011 Attention Disorder Drugs Appendix V: Studies Related to Diversion or Abuse of Methylphenidate by School-Aged Children
a This method of questioning may underestimate the use of ADHD drug use because students may not know that these drugs are amphetamines. b Out of 554,932 occurrences of emergency department drug treatments, methylphenidate was mentioned 1,478 times. Methylphenidate is not in the top 15 most frequently mentioned drugs for 6 to 17 year olds. Sources: Monitoring the Future - http://www.monitoringthe future.org/ Indiana Prevention Resource Center - http://www.drugs.indiana.edu/ Massachusetts Department of Public Health - http://www.state.ma.us/dph/pubstats.htm National Household Survey on Drug Abuse - http://www.samhsa.gov/oas/p0000016.htm Drug Abuse Warning Network (DAWN) - http://www.icpsr.umich.edu/SAMHDA/dawn.html National Institute of Justice’s Arrestee Drug Abuse Monitoring (ADAM) – http://www.adam-nji.net
Page 39 GAO-01-1011 Attention Disorder Drugs Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Appendix VI: StateAdministration Statutes, of Medication to Students Regulations, and Mandatory Policies Addressing the Administration of Medication to Students
Page 40 GAO-01-1011 Attention Disorder Drugs Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students
Page 41 GAO-01-1011 Attention Disorder Drugs Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students
Page 42 GAO-01-1011 Attention Disorder Drugs Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students
Page 43 GAO-01-1011 Attention Disorder Drugs Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students
Page 44 GAO-01-1011 Attention Disorder Drugs Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students
aThe California respondent told us that the implementing regulations are being drafted. bThe respondent for the District of Columbia told us that currently there are no implementing rules or regulations. cThe regulation requires either a pharmacy label or the physician’s prescription. See 511 Ind. Admin. Code 7-21-8(a)(3). In addition, although the regulation does not require schools to obtain a physician’s written orders, an Indiana statute provides immunity from liability to school employees who administer prescription medication in compliance with the parent’s or guardian’s written permission and the practitioner’s written orders. See Ind. Code 34-30-14-2. dThe Maine statute also requires the state commissioner of education to adopt rules for medication administration in schools, including training requirements for unlicensed personnel. The Maine respondent told us that the rules have been proposed but not yet enacted. eThe regulation requires either the physician’s instructions or a pharmacy label. Oregon Admin. Rules, 581-021-0037(1)(c). fThe Pennsylvania respondent told us that currently there are no implementing guidelines in effect. gThe pharmacy-container requirement is specific to self-administered medications. Code of Rhode Island Rules 14-000-011, sec. 18.9.1.1. hThe South Dakota respondent told us that the state board of education has not promulgated rules under the statute, but that the state department of health has issued discretionary guidelines addressing medication administration in schools.
Page 45 GAO-01-1011 Attention Disorder Drugs Appendix VII: GAO Contacts and Staff Appendix VII: GAOAcknowledgments Contacts and Staff Acknowledgments
Paul Jones, (202) 512-8777 GAO Contacts Darryl W. Dutton, (213) 830-1000
William Bates, Christine Davis, Jennifer Joseph, Stuart Kaufman, Monica Acknowledgments Kelly, Lawrence Kinch, Lori Levitt, Mark Ramage, Anne Rhodes-Kline, and Lisa Wallace.
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